The effect of rotationplasty on the ankle joint: long-term results

Rotationplasty Salvage Procedure as an Effective Alternative to Femoral Amputation in an Adult With a History of Osteosarcoma: A Case Report and Review

Rotationplasty or Borggreve-Van Ness surgery is lower limb salvage surgery, indicated mainly in the management of femoral bone sarcoma and congenital femur malformations in children. It can also be an interesting surgery option for managing chronic osteoarticular infections, or in cases of non union when curative therapy is no longer an option, as an alternative to femoral amputation. The principle of this surgery is to remove the affected knee and to apply a rotation of 180° to the distal part of the lower limb in order to give the ankle the function of a neo-knee. With the help of an adapted prosthesis, the aim is to allow patients to resume their social and professional activities by keeping most of their lower limb, thus avoiding the known complications of amputation (ghost limb pain, proprioceptive deficit, psychological disorders). Nevertheless, this surgery is complex and exceptional, with vascular, infectious, and psychological risks - the chimeric aspect of the lower limb may cause significant ill-being for the patient. This article reports the case of a 38-year-old patient consulting for management of a complex septic distal femoral non-union following osteosarcoma considered as being in remission. The patient underwent rotationplasty surgery on his left lower limb, with very good functional results and no surgical revision to date. In light of this particular case, we propose a didactic overview of the literature data concerning this surgery, especially in adulthood.

Straightplasty, a Limb Salvage Procedure in Malignant and Aggressive Bone Tumors of Lower Extremities: A Retrospective Analysis

Introduction The management of malignant bone tumors of lower extremities involves various modalities, which depend not only on local and systemic affection but are also affected by psychosocial factors. The purpose of this study was to evaluate functional and psychosocial outcomes in patients with non-salvageable lower limbs having malignant or aggressive benign bone tumors of distal thighs, who were treated with a technique called straightplasty. Material and methods We enrolled 20 patients of non-salvageable primary malignant or aggressive benign bone tumors around the knee. Out of these, 15 patients were followed and evaluated in view of functional and clinical outcomes having a minimum of 22 months of final follow-up. Results A total of 15 patients (8 males, 7 females) having a non-salvageable lower limb with a mean age of 20.53 years (range, 12 to 45 years), who were managed with straightplasty and followed for a mean duration of 31.73 months (range 22 to 72 months) were evaluated clinico-radiologically, and the functional outcomes were measured by Enneking' s method. The surgical procedure is simple and better in terms of functional outcomes than other procedures described in the literature, while it is observed as psychosocially more acceptable in developing nations, especially in the Indian context. Most of the parameters are comparable to rotationplasty and above-knee amputation, whereas it is less technically demanding and satisfying due to the straight limb rather than the rotated leg in rotationplasty. Conclusion We recommend straightplasty as an alternative to rotationplasty or above-knee amputation in patients having malignant or aggressive benign tumors around the knee joint and where limb salvage procedures are not feasible.

Does Osteoarthritis of the Ipsilateral Hip Develop After Knee Rotationplasty? A Radiologic Study on Patients with Long-term Survival Undergoing Surgery for Bone Tumors

BACKGROUND

During routine check-ups of long-term surviving knee rotationplasty patients referred to our institute, we noted that the operated limb radiograph showed signs of hip osteoarthritis in some patients, and that one patient reported hip pain. We wondered whether radiographic changes and symptoms are common in patients undergoing rotationplasty due to mechanical or overloading problems during gait. Based on these considerations, we wished to determine how frequently arthrosis or arthritis would arise in the ipsilateral hip to a knee rotationplasty at long-term follow-up. To our knowledge, this issue has not been explored. Clinicians and patients should be aware of any problems that may affect the hip over time that could result in treatment.

QUESTIONS/PURPOSES

At a minimum of 10 years after rotationplasty, in a single-center series, we therefore asked: (1) What proportion of patients reported hip pain at rest and with activity? (2) What proportion have radiographically visible arthritic changes in the ipsilateral or contralateral hip? (3) What proportion of patients have changes in the hip morphology (femoral rotation, cervicodiaphyseal angle, acetabular angle, osteopenia)?

METHODS

Between 1986 to 2009, 42 patients underwent rotationplasty in our institute. They represent the 16.5% of a series of 254 children (age 3 to 14 years) affected by high-grade bone sarcomas located in the distal half of the femur. Three more patients were adolescents older than 15 years and were treated with rotationplasty because of the tumor volume and extracompartmental involvement. Of these 45 patients, 14 died of disease at a mean of 37 months; 31 patients were survivors at the time the study was done. Three of these long-term survivors were known to be alive but did not come for a clinic visit in the last 5 years. The remaining 28 patients were invited to participate in a research study on the long-term assessment of rotationplasty, and all agreed to participate. Unfortunately, 10 patients living far from our Institute could not come in the 2 days established for the assessment due to family or work constraints. AP plain radiographs of the pelvis were taken in 17 patients with long-term survival after knee rotationplasty. Patients were positioned in a standard weightbearing position, wearing their own prosthesis. Hip osteoarthritis was assessed using the Croft grading system. The presence of hip pain was assessed with the self-reported Numeric Rating Scale (NRS), with scores ranging from 0 to 10, at rest and during daily life activities. Femoral rotation, osteopenia, the cervicodiaphyseal and the acetabular angles were measured on radiographs. The median (range) age at follow-up was 32 years (22 to 45), the median age at the time of the intervention was 9 years (6 to 17), and the median follow-up duration after surgery was 25 years (11 to 30).

RESULTS

One of the 17 patients complained of mild pain (NRS score of 2) in the ipsilateral hip during walking. No other patient claimed to have hip pain at rest or during walking or other daily life activities. Eleven of 17 patients had signs of OA according to the Croft grading system: one had Grade 1 OA, seven had Grade 2, and three had Grade 3. Six patients did not show any sign of OA in the ipsilateral hip. Two patients had Grade 1 OA and one had Grade 2 OA of the contralateral hip. Sixteen patients had femoral external rotation. An increased valgus cervicodiaphyseal angle and acetabular angle were present in 10 and 9 patients, respectively. Osteopenia at the ipsilateral hip when compared with the contralateral, was present in all patients but one, with varying degrees of severity.

CONCLUSIONS

In this small series, signs of osteoarthritis of the hip ipsilateral to the rotationplasty were present in a high proportion of patients at a minimum follow-up interval of 10 years after surgery, although only one participant reported hip pain. The finding of arthrosis in the hip above a rotationplasty is potentially important because it may be related to gait abnormalities that may modify the hip's morphology over time. It is encouraging that symptomatic hip pain was uncommon in our patients, but this could become more of a clinical problem with longer follow-up and result in therapeutic intervention. Patients (or the parents of patients) undergoing this procedure should be informed that they might develop hip arthritis during young adulthood.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Rehabilitation and Prosthetic Design after Van Nes Rotationplasty of the Left Leg Due to Severe Burn Contractures in a Patient with Contralateral Amputated Right Femur: A Case Report

Background:

Van Nes Rotationplasty (VNRP) is a biological reconstructive surgical method for pediatric sarcoma, complex trauma or severe lower limb deficiencies that often gets overlooked due to cosmetic reasons and psychological aspects. We report a unique case of knee stiffness and severe scarring from burns treated with this technique in a young patient who had also amputated contralateral femur.

Case Report:

A 15-year-old boy was trapped in a fire 10 years ago and sustained extensive contractures on his left knee due to severe burns and also an above knee amputation on his right thigh. For 10 years the boy had never received rehabilitation or worn any prosthesis and he managed to move bearing mainly on his palms. On admission to our hospital Van Nes rotationplasty was preferred among other treatment options as the most suitable solution for him and was successfully performed without complications.

The patient had severe stiffness on his right hip and decreased muscle power in the VNRP leg but after intensive physiotherapy he was able to stand upright and walk again using custom made bilateral prostheses and crutches.

Conclusion:

VNPR is a reasonable option in severe contractures and scarring of the knee joint.

Pediatric Malignant Bone Tumors: A Review and Update on Current Challenges, and Emerging Drug Targets

Osteosarcoma (OS) and the Ewing sarcoma family of tumors (ESFT) are the most common malignant bone tumors in children and adolescents. While significant improvements in survival have been seen in other pediatric malignancies the treatment and prognosis for pediatric bone tumors has remained unchanged for the past 3 decades. This review and update of pediatric malignant bone tumors will provide a general overview of osteosarcoma and the Ewing sarcoma family of tumors, discuss bone tumor genomics, current challenges, and emerging drug targets.

How Much Clinical and Functional Impairment do Children Treated With Knee Rotationplasty Experience in Adulthood?

BACKGROUND

Rotationplasty may be indicated for some children with osteosarcoma in the distal femur or proximal tibia; in properly selected patients, it may offer functional advantages over transfemoral amputation and more durable results than a prosthesis. The clinical and functional outcomes reported for this procedure generally have been limited to studies with a mean followup of approximately 8 years in terms of Musculoskeletal Tumor Society Score (MSTS), physical examination, and gait analysis. However, the effects of residual thigh-shank length on gait have not been explored to our knowledge.

QUESTIONS/PURPOSES

We asked: (1) Do differences in the length of the surgically treated residual thigh-shank relative to the contralateral thigh result in altered gait patterns? (2) What were the clinical and functional impairments and radiographic findings of patients who underwent rotationplasty and who survived to adulthood? (3) Do gait analysis findings in adults differ from previously reported findings in children in terms of relevant gait parameters such as maximal ground reaction forces and sagittal knee angles?

METHODS

From January 1986 to December 2009, 254 children (age range, 3-14 years) affected by high-grade bone sarcomas located in the distal half of the femur were surgically treated at our institute. Forty-two of these patients (16.5%) underwent rotationplasty. During this period, three adolescents older than 15 years were treated by rotationplasty owing to the tumor volume and extracompartmental involvement. In total, 45 patients underwent rotationplasty. From January 1986 to December 2000, rotationplasty generally was the preferred treatment for patients younger than 9 years with a high-grade bone sarcoma calling for an intra- or extraarticular resection of the distal femur, as long as the sciatic nerve could be spared. From January 2001, the procedure was not used as often. Of the 45 patients who underwent a rotationplasty, 14 died of disease at a mean of 37 months (31%); 31 patients (69%) were survivors at the time the study was done, 29 of whom were continuously disease free (64%) and two had no evidence of disease after a pulmonary metastasectomy (5%). These 31 patients were invited to participate in the study, and 25 of the 31 agreed to participate. There were 15 males and 10 females with a mean age of 23.8 years (SD, 7.5 years) and mean followup of 15 years (SD, 5.8 years). Clinical assessment included the MSTS score (total score ranges between 0 and 30 with 0 indicating poor results and 30 indicating good results), obtained by clinical assessment and patient interview, measurements of the residual thigh-shank length and of the contralateral thigh, of the lengths of the surgically treated and contralateral feet, and of active ROM of the rotated and contralateral ankles. Of the 25 patients, 22 (88%) agreed to have lower limb radiographs and 16 (64%) agreed to perform gait analysis.

RESULTS

The residual thigh-shank was, on average, 5.8% longer than the contralateral thigh. Differences in the length of the residual thigh-shank relative to the contralateral thigh resulted in altered gait patterns. Patients with longer residual thigh-shank length had greater pseudoknee flexion during stance and swing. Patients with shorter residual thigh-shank length walked with a gait similar to that of controls. The mean MSTS score was 25 (SD, 2). With respect to the contralateral foot, the surgically treated foot was 10% shorter, the talus 11% shorter in the long axis and 7.6% in the short axis and the calcaneus was 2.7% shorter in the long axis and 8.6% in the short axis. Radiologic arthritis was present in most patients at the tibiotalar, subtalar, and talonavicular joints. As adults, our patients showed improved gait parameters compared with previously reported findings for children undergoing rotationplasty. Vertical ground reaction force during midstance was reduced by 6% and knee ROM during the gait cycle was increased by 24.6°.

CONCLUSIONS

The residual thigh-shank length influences the gait performance, such that patients with smaller discrepancies between the surgically treated and contralateral sides had the best walking performance. The MSTS score at a mean of 15 years after knee rotationplasty confirmed the results reported in the shorter-term for function and pain. The foot on the surgically treated side was smaller than the contralateral foot, and degenerative changes were present, which could contribute to impaired function. Gait performance, in terms of ground reaction forces and knee ROM, was improved in our adult patients although a difference in loading was still present between the surgically treated and contralateral limbs. Based on these findings, surgeons should endeavor to have the center axis of rotation of the contralateral knee and pseudoknee at skeletal maturity. An excessive residual thigh-shank length in adult patients could require contralateral lengthening to improve functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors

BACKGROUND

Malignant bone tumors of the lower extremity are more frequently found in children and adolescents than in adults. Modern treatment regimens led to high limb salvage rates and offer the choice between endoprosthetic replacement and rotationplasty in many cases. Rotationplasty has proven to be an effective, highly functional option in short- and mid-term studies. Aim of this study was to assess long-term results regarding quality of life and functionality after rotationplasty and to compare the obtained results to a representative healthy German sample cohort.

METHODS

In total 12 patients who underwent rotationplasty between 1991 and 2001 were enrolled in this study. After physical examination, they were evaluated regarding health related quality of life, functional outcome and psychosocial status. While quality of life was mainly assessed using the SF-36 (The Short Form (36) Health Survey v2), functional outcome was measured using the musculoskeletal tumor society score (MSTS) as well as the Tegner activity level scale.

RESULTS

Average age at the time of surgery was 19 ± 10 year. and 32 ± 11 year. at the time of follow up. Mean follow-up was 14 ± 9 years. The SF-36 scores accounted for 80.4 ± 15.7 regarding physical functioning, for 78.1 ± 24.1 regarding the physical role functioning, for 74.1 ± 17.6 regarding bodily pain and for 71.8 ± 26.1 regarding general health. SF-36 score for vitality was 75.0 ± 12.8, for social functioning 98.9 ± 3.6, 88.2 ± 23.9 for emotional role functioning and 89.6 ± 10.1 for the mental health. Comparison to a representative German sample cohort revealed significantly higher patient's scores for vitality, social functioning and mental health (p < 0.05). The overall MSTS resulted in an average of 64 ± 12 % and the Tegner activity level scale accounted for 4.1 ± 0.6 pts.

CONCLUSIONS

The presented long-term results indicate that rotationplasty provides a high quality of life. Patients are satisfied with a good functional outcome regarding activities of daily life and even sports.

Eighteen-year follow-up after rotationplasty for a grade IIIC open fracture of the distal femur

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49 years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up.

Exceptional functional recovery and return to high-impact sports after Van Nes rotationplasty

Rotationplasty involves wide resection of lower-extremity malignancy and approximately 180° rotation of the tibia to allow the ankle to function similarly to the former knee joint. It is most commonly used for sarcomas around the knee, such as the distal femur and proximal tibia, in adolescent and young adult patients and is an option for patients with proximal femoral focal deficiency (congenital short femur). Rotationplasty is an alternative to ablative procedures when functional outcome is a consideration or when resection of involved areas and endoprosthetic reconstruction is not possible. This article describes functional status and return to competitive sport after rotationplasty for a lower-extremity bone sarcoma with 3-year follow-up. Despite a postoperative course complicated by a distal tibial physeal injury and femoral neck stress fracture, the patient recovered fully by 1 year postoperatively. Pain free at rest and with activity and with no loss of function, the patient is a successful athlete, playing basketball and baseball and skiing competitively. The patient used a custom-made prosthesis that likely played a role in his high level of function. The patient's high function is evidenced by a maximal or near-maximal possible score on all subsections of the Short Form 36 health survey. Although this level of function is exemplary, it may be more expected in younger, more active, highly motivated, and emotionally and socially mature individuals.

Rotationplasty in the elderly

Purpose. Rotationplasty has proven its efficacy in the treatment of malignant bone tumors of the lower extremity in predominantly young patients. To our knowledge this procedure has not been reported in patients over 60 years before. Materials and Methods. 3 patients over 60 years with an A1-rotationplasty because of a sarcoma were included in this study. Complications and functional results were recorded. In one patient an electromyography was done. Results. Despite electromyography showing good adaptation of the muscles to the altered function, the functional results of these three patients were limited. two out of three patients needed a cane for walking distances over 200 meters. No secondary amputation was necessary. Discussion. Our study demonstrates that rotationplasty is an alternative to an above-knee amputation in older patients but with poorer functional results in comparison to younger patients. However, limb-salvage surgery should be preferred whenever possible.

Improvement of the soft socket after rotationplasty: a single case study

Rotationplasty is established as a functionally improving and partially ablative method of tumour surgery, but good clinical and functional results do not only depend on a successful surgery. Due to the changed biomechanical situation the activity level is limited by the weight bearing capacity of the rotated foot. Painful blisters and callosities may limit the use of the exo-prosthesis, because the skin is overstressed in the soft socket. A 28-year-old patient with a rotationplasty type A2 suffered from painful callosities of the rotated foot. Capacitive pressure measurements were performed as well as a gait analysis for kinematics and kinetic characteristics. Clinically a decrease of the callosities and a pain relieve was obvious and the patient learned skiing without prior knowledge. Biomechanically a decrease of the peak pressure (from 240.6-135.0 kPa) and the mean pressure (from 83.2-66.2 kPa), was observed with an increased weight bearing area. The study has shown that a modification of the heel bench can considerably improve pressure distribution. An increase of the load bearing area appears to enable the skin to compensate even intensive strain during athletic activities.